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Advanced ENT Training
Advanced ENT Training
A Guide to Passing the FRCS
(ORL-HNS) Examination

Edited by
Joseph Manjaly
MBChB BSc (Hons) DOHNS FRCS (ORL-HNS)
Consultant ENT Surgeon
The Royal National ENT Hospital and University
College London Hospitals, United Kingdom

Peter Kullar
MA MB BChir DOHNS MRCS PhD
NIHR Clinical Lecturer and Academic ENT Trainee
Cambridge University Hospitals, United Kingdom

with exam pearls from ENT senior trainees and

consultants from around the United Kingdom
CRC Press
Taylor & Francis Group
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© 2020 by Taylor & Francis Group, LLC

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International Standard Book Number-13: 978-0-367-20251-4 (Paperback)

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 For Sarah and Joshua Manjaly

For Kirsty, Max and Cassia Kullar

Contents
Foreword xiii
Editors xv
Senior Section Editors xvii
Contributors xix
Abbreviations xxi

CHAPTER 1 INTRODUCTION 1
JOSEPH MANJALY AND PETER KULLAR

CHAPTER 2 PERSONAL REFLECTIONS ON THE FRCS

(ORL-HNS) PART 1 EXPERIENCE 3
ALISON CARTER

CHAPTER 3 GENERAL ADVICE FOR PREPARING FOR PART 2 7

JOSEPH MANJALY

CHAPTER 4 HISTORIES AND EXAMINATIONS IN THE PART 2

CLINICAL SECTION 11
JOSEPH MANJALY AND PETER KULLAR

Examining the ‘Dizzy’ Patient 16

MANOHAR BANCE

CHAPTER 5 COMMON HEAD AND NECK VIVA TOPICS 25

EDITED BY JAMES O’HARA

Benign Laryngeal Lesions 26

CHADWAN AL-YAGHCHI

Deep Neck Space Infections 29

MOHIEMEN ANWAR

Hypercalcaemia and Hypocalcaemia 33

ZI-WEI LIU

Hypopharyngeal Cancer 35
LAURA WARNER

Laryngeal Cancer 38
LAURA WARNER

Nasopharyngeal Cancer 42
JASON FLEMING

Neck Dissection and Accessory Nerve Palsy 45

JAGDEEP VIRK

Obstructive Sleep Apnoea (OSA) 48

ZI-WEI LIU

Oral Cavity Cancer 50

JASON FLEMING

vii
 viii Contents

Oropharyngeal Cancer 54
LAURA WARNER

Penetrating Neck Trauma 58

JASON FLEMING

Pharyngeal Pouch 61
JAGDEEP VIRK

Post-laryngectomy Care 64
JASON FLEMING

Post-laryngectomy Complications 67
ZI-WEI LIU

Radiotherapy, Chemotherapy and Osteoradionecrosis 69

JAGDEEP VIRK

Ranula 72
CHADWAN AL-YAGHCHI

Salivary Gland Malignancy 74

JAGDEEP VIRK

Sialolithiasis 77
CHADWAN AL-YAGHCHI

Thyroid Pathology 79
ZI-WEI LIU

Unknown Primary Cancer in the Head and Neck 82

LAURA WARNER

Vocal Cord Palsy 86

CHADWAN AL-YAGHCHI

CHAPTER 6 COMMON OTOLOGY VIVA TOPICS 91

EDITED BY JAMES R TYSOME AND NEIL DONNELLY

Air Conduction Hearing Devices 92

JAMEEL MUZAFFAR AND SUSAN EITUTIS

Benign Paroxysmal Positional Vertigo 94

NICHOLAS DAWE

Bone Conduction Hearing Implants and Middle Ear Implants 98

JAMEEL MUZAFFAR AND JOSEPH MANJALY

Cerebellopontine Angle Tumours 102

NISHCHAY MEHTA

Cholesteatoma 105
NICHOLAS DAWE

Chronic Otitis Media 110

JOSEPH MANJALY

Cochlear Implantation 113

ROBERT NASH AND JOSEPH MANJALY
 Contents ix

Ear drops and Anaesthetics 116

JOSEPH MANJALY

Facial Palsy 117

NISHCHAY MEHTA

Ménière’s disease 121

KIRAN JUMANI AND PETER KULLAR

Necrotising Otitis Externa 126

NISHCHAY MEHTA

Noise-induced Hearing Loss 129

JAMEEL MUZAFFAR

Non-organic Hearing Loss 132

KIRAN JUMANI

Ossiculoplasty 135
NIKUL AMIN

Otosclerosis 139
JOSEPH MANJALY

Paraganglioma 143
PETER KULLAR

Pre-auricular Sinus 147

NIKUL AMIN

Sensorineural Hearing Loss, Presbyacusis, Autoimmune Hearing

Loss 149
NIKUL AMIN

Sudden Sensorineural Hearing Loss 152

NICHOLAS DAWE

Temporal Bone Fracture 156

KIRAN JUMANI AND PETER KULLAR

Tinnitus 160
NISHCHAY MEHTA

Vertigo 162
NICHOLAS DAWE

CHAPTER 7 COMMON PAEDIATRIC ENT VIVA TOPICS 169

EDITED BY BENJAMIN HARTLEY AND RICHARD J HEWITT

Branchial Anomalies 170

JESSICA BEWICK

Cervical Lymphadenopathy 172

JESSICA BEWICK

Choanal Atresia 174

MATTHEW ELLIS

Cleft Lip and Palate 178

SUNIL SHARMA
 x Contents

Congenital Midline Nasal Masses 182

SUNIL SHARMA

Developmental Milestones, Hearing and Speech, Autism 184

JESSICA BEWICK

Drooling 186
GARETH LLOYD

Juvenile Nasopharyngeal Angiofibroma 188

COLIN BUTLER

Laryngomalacia 192
MATTHEW ELLIS

Microtia 195
SUNIL SHARMA

Obstructive Sleep Apnoea 197

LAKHBINDER PABLA

Otitis Media 201

ROBERT NASH

Paediatric Airway Compromise 204

LAKHBINDER PABLA

Paediatric Hearing Loss 211

ROBERT NASH AND JOSEPH MANJALY

Periorbital Cellulitis 216

GARETH LLOYD

Recurrent Respiratory Papillomatosis 220

LAKHBINDER PABLA

Syndromes in ENT 222

SUNIL SHARMA

Thyroglossal Duct Cyst 227

JESSICA BEWICK

Tonsillitis and Post-Tonsillectomy Bleeding 230

GARETH LLOYD

Vascular Malformations 234

MATTHEW ELLIS

CHAPTER 8 COMMON RHINOLOGY AND FACIAL PLASTICS VIVA TOPICS 239

EDITED BY HESHAM SALEH

Acute Sinonasal Infections 240

MOHIEMEN ANWAR

Allergic Rhinitis and Nasal Steroids 244

THOMAS JACQUES

Anosmia 248
MARK FERGUSON
 Contents xi

Chronic Rhinosinusitis 250

MARK FERGUSON

CSF Rhinorrhoea 253

MOHIEMEN ANWAR

Endoscopic Sinus Surgery 256

MOHIEMEN ANWAR

Epistaxis 259
SAMIT UNADKAT

Facial Flaps and Reconstruction 262

THOMAS JACQUES

Facial Pain 267

THOMAS JACQUES

Fungal Sinusitis 270

MOHIEMEN ANWAR

Hereditary Haemorrhagic Telangiectasia 273

MARK FERGUSON

Keloids 276
THOMAS JACQUES

Olfactory Neuroblastoma 279

MARK FERGUSON

Pinnaplasty 282
SAMIT UNADKAT

Septal Perforation 285

MARK FERGUSON

Septorhinoplasty288
SAMIT UNADKAT

Sinonasal Tumours 292

MOHIEMEN ANWAR

Skin Cancer 295

SAMIT UNADKAT

Index 299
Foreword
Joseph Manjaly and Peter Kullar bring energy and enthusiasm to all their endeavours. I know
both well following their time in Cambridge. Joseph completed his otology and hearing implant
training at Addenbrooke’s before taking up a consultant post at the Royal National Throat,
Nose and Ear Hospital. Peter is following an academic career and is destined to shape ­academic
otolaryngology over the years to come. Both have a passion and commitment that they want
to bring to the task of educating young surgeons, understanding that the FRCS (ORL-HNS)
(Fellowship of the Royal Colleges of Surgeons [Otorhinolaryngology – Head and Neck Surgery])
examination is a hurdle that weighs heavily on senior trainees who have so little free time.
Our surgical training programme is not only for learning a curriculum and surgical technique,
but also for developing higher order thinking skills that make us problem solvers, deep thinkers,
bold innovators, collaborative team players and assertive leaders. It seeks an intrinsic motivation
for learning and research to discover the joy in our speciality. My role in ENT training comes
towards the senior years – to take a senior trainee and help him or her become an otologist or
skull base surgeon equipped to take our speciality forward. But to ensure transformative learn-
ing in the final fellowship years there needs to be core knowledge and experience applying that
knowledge. The earlier a trainee starts down this road, the more valuable each patient contact
becomes.
Advanced ENT Training: A Guide to Passing the FRCS (ORL-HNS) Examination presents insight
into an examination that is shrouded in mystery and conflated by half-truths. Joseph and Peter
have carefully considered our curriculum and analysed every step of the examination to ­create
a structure for learning that focusses on the task of attaining a good pass. Examiners want con-
cise and well-structured answers about the investigation, diagnosis and management of ENT
­pathology. This book directs readers to the critical topics, highlights what an examiner regards as
important core knowledge, and describes how best to structure answers when under pressure to
perform. There are, however, benefits to reading this book at the beginning of training. For those
just starting ENT training, it is difficult to know where to direct those first efforts which are cur-
rently dictated by departmental interests often without evidentiary basis. This book gives a suc-
cinct overview of what will be required over the years to come. It describes directed examination
that is designed to diagnose. Examining a dizzy patient, for example, should not evoke horror but
a growing confidence built on perfecting technique. To achieve their goal, Joseph and Peter have
brought together colleagues from around the UK who have also recently excelled in the FRCS
(ORL-HNS) examination. They bring a personal and up-to-date perspective on the examination,
sharing their experience and tips. Senior editors who are at the top of our profession bring further
insight into key topics that require particular attention.
In the following chapters you will learn all you need to know about how to pass the FRCS (ORL-
HNS) examination. Examination skills and viva strategies are key components to making the
grade. You’ll learn model answers, pearls of wisdom, essential checklists in ‘must-know’ areas
and pointers for further reading. Advanced ENT Training: A Guide to Passing the FRCS (ORL-
HNS) Examination is a concise book designed to structure your learning in the most effective
way. I therefore encourage you to read what will become the most important first and last book
a trainee will read.

Patrick Axon, MBChB MD FRCS (ORL-HNS)

Consultant Otologist and Skull Base Surgeon
Cambridge University Hospitals

xiii
Editors
Joseph Manjaly is a consultant ENT surgeon at the Royal National ENT Hospital and University
College London Hospitals, specialising in otology and auditory implant surgery. He completed
higher surgical training in the London North Thames region and subsequently undertook a fel-
lowship in otology and hearing implantation at Cambridge University Hospitals. He has held an
interest in teaching since his undergraduate years at Bristol University and co-authored the first
edition of the MasterPass book ENT OSCEs: A Guide to Passing the DO-HNS and MRCS (ENT)
OSCE with Peter Kullar whilst a core trainee in Wessex Deanery. He has been actively involved
in training issues regionally and nationally, holding a number of committee roles within the
Association of Otolaryngologists in Training. In addition to being a keen sports fan he is also a
musician who performs semi-professionally around the country with a band.
Peter Kullar is an NIHR clinical lecturer at Cambridge University Hospitals, having previously
been a Wellcome Trust Clinical Research Fellow and academic ENT trainee in the Northern
Deanery. He graduated from Cambridge University and subsequently completed a PhD from the
same institution where his work elucidated mechanisms of mitochondrial-associated hearing
loss. Peter co-authored the MasterPass book ENT OSCEs: A Guide to Passing the DO-HNS and
MRCS (ENT) OSCE with Joseph Manjaly after they met during a course and concurred that there
was a need for such a book amongst ENT trainees. Peter has held an active role in teaching and
maintains a number of research streams with a specialist interest in otology.

xv
Senior Section Editors
Manohar Bance, MBChB, MSc, FRCSC, FRCS, ABOto
Professor of Otology and Skull Base Surgery
University of Cambridge
and
Honorary Consultant
Cambridge University NHS Foundation Hospitals Trust
Cambridge, United Kingdom

Neil Donnelly, MBBS, MSc, FRCS (ORL-HNS)

Consultant ENT and Skull Base Surgeon
Cambridge University Hospitals
Cambridge, United Kingdom

Benjamin Hartley, FRCS

Consultant Paediatric Otolaryngologist
Great Ormond Street Hospital for Children
London, United Kingdom

Richard J Hewitt, BSc, FRCS (ORL-HNS)

Consultant Paediatric ENT, Head and Neck and Tracheal Surgeon
Great Ormond Street Hospital for Children
London, United Kingdom

James O’Hara, FRCS (ORL-HNS)

Consultant Otolaryngologist, Head and Neck Surgeon
The Freeman Hospital
Honorary Senior Clinical Lecturer
Newcastle University
Newcastle upon Tyne, United Kingdom

Hesham Saleh, FRCS (ORL-HNS)

Consultant Rhinologist/Facial Plastic Surgeon
Charing Cross and Royal Brompton Hospitals
Imperial College London
London, United Kingdom

James R Tysome, MA, PhD, FRCS (ORL-HNS)

Consultant ENT and Skull Base Surgeon
Cambridge University Hospitals
Cambridge, United Kingdom

xvii
Contributors
Chadwan Al-Yaghchi, MD, PhD, FRCS
(ORL-HNS)
Consultant ENT Surgeon
Imperial College Healthcare NHS Trust
London, United Kingdom
Nikul Amin, FRCS (ORL-HNS)
ENT Specialty Registrar
London Deanery – South
London, United Kingdom
Mohiemen Anwar, MBBS, PhD, FRCS
(ORL-HNS)
Consultant ENT Surgeon
Chelsea and Westminster NHS Foundation
Trust
London, United Kingdom
Jessica Bewick, MA, FRCS (ORL-HNS)
Consultant Paediatric ENT Surgeon
Cambridge University Hospitals NHS Trust
Cambridge, United Kingdom
Colin Butler, PhD, FRCS (ORL-HNS)
Paediatric ENT Fellow
Great Ormond Street Hospital for Children
London, United Kingdom
Alison Carter, BMedSci(Hons), BMBS,
DOHNS, FRCS (ORL-HNS)
ENT Specialty Registrar
London Deanery – North
London, United Kingdom
Nicholas Dawe, FRCSEd (ORL-HNS), MRes,
DipMedEd
Otology and Lateral Skull Base Fellow
Queen Elizabeth Hospital
University Hospitals Birmingham
Birmingham, United Kingdom
Susan Eitutis, BSc, MSc, MCISc
Research Audiologist
Emmeline Centre for Hearing Implants
Cambridge University Hospitals NHS Trust
Cambridge, United Kingdom
Matthew Ellis, MBBS, MPhil, FRCS
(ORL-HNS)
ENT Specialty Registrar
Northern Region
London Deanery – North
London, United Kingdom
Mark Ferguson, PhD, FRCS (ORL-HNS)
Royal College of Surgeons of England
Rhinology Fellow
Imperial College Healthcare NHS Trust
London, United Kingdom
Jason Fleming, MBBS Med, FRCS (ORL-HNS),
PhD
Head and Neck Fellow
University of Alabama
Birmingham, Alabama
Thomas Jacques, MA (Cantab), FRCS
(ORL-HNS)
ENT Specialty Registrar
London Deanery – North
London, United Kingdom
Kiran Jumani, MS (ENT), DNB
(Otolaryngology), FRCS (ORL-HNS)
Consultant ENT Surgeon
County Durham and Darlington NHS
Foundation Trust
Darlington, United Kingdom
Zi-Wei Liu, MBBS, FRCS (ORL-HNS)
ENT Specialty Registrar
London Deanery – North
London, United Kingdom
Gareth Lloyd, BMBS, BMedSci(Hons), FRCS
(ORL-HNS)
ENT Specialty Registrar
London Deanery – South
London, United Kingdom
Nishchay Mehta, PhD, FRCS (ORL-HNS)
ENT Specialty Registrar
London Deanery – North
London, United Kingdom
xix
 xx Contributors
Jameel Muzaffar, BA (Hons), MBBS (Hons),
MSc, FRCS (ORL-HNS)
ENT Specialty Registrar and Research Fellow/
PhD Student
Department of Clinical Neurosciences
University of Cambridge
Cambridge, United Kingdom
and
Academic Department of Military Surgery and
Trauma
Royal Centre for Defence Medicine
University Hospitals Birmingham NHS
Foundation Trust
Birmingham, United Kingdom
Robert Nash, MA(Oxon), DOHNS, FRCS
(ORL-HNS), MA (KCL)
Consultant Otologist and Cochlear Implant
Surgeon
Great Ormond Street Hospital for Children
London, United Kingdom
Lakhbinder Pabla, BMBCh MA (Oxon),
DOHNS, FRCS (ORL-HNS), PGDipMedEd
Paediatric ENT Fellow
The Royal Children’s Hospital
Melbourne, Australia
Sunil Sharma, MBBS, BSc (Hons), FRCS
(ORL-HNS)
Consultant Paediatric ENT Surgeon
Alder Hey Children’s NHS Foundation Trust
Liverpool, United Kingdom
Samit Unadkat, FRCS (ORL-HNS)
ENT Specialty Registrar
London Deanery – North
London, United Kingdom
Ananth Vijendren, BM, FRCS
(ORL-HNS), PhD
Regional Otology and Implant Fellow
Cambridge University Hospitals NHS Trust
Cambridge, United Kingdom
Jagdeep Virk, MA, FRCS (ORL-HNS),
PGCertMedEd
Head and Neck Fellow
Imperial College Healthcare NHS Trust
London, United Kingdom
Laura Warner, FRCS (ORL-HNS)
Consultant ENT Surgeon
The Newcastle upon Tyne Hospitals
NHS Trust
Newcastle upon Tyne, United Kingdom
Abbreviations
A&E accident and emergency
AABR automated auditory brainstem response
ABC airway, breathing, circulation
ABR auditory brainstem response
ACC adenoid cystic carcinoma
ACE angiotensin-converting enzyme
ACP antrochoanal polyp
AHI apnoea–hypopnoea index
AICA anterior inferior cerebellar artery
AJCC American Joint Committee on Cancer
ANCA antineutrophil cytoplasmic antibody
ARCP Annual Review of Competence Progression
ARIA allergic rhinitis and its impact on asthma
ATLS Advanced Trauma Life Support
AVM arteriovenous malformation
BAHA bone-anchored hearing aid
BC bone conduction
BCC basal cell carcinoma
BDD body dysmorphic disorder
BiCROS bilateral contralateral routing of signal
BIH benign intracranial hypertension
BMI body mass index
BPPV benign paroxysmal positional vertigo
BSACI British Society for Allergy & Clinical Immunology
CBT cognitive behavioural therapy
CMV cytomegalovirus
CN cranial nerve
CNS central nervous system
COWS cold opposite, warm same
CPA cerebellopontine angle
CPAP continuous positive airway pressure
CROS contralateral routing of signal
CRP C-reactive protein
CRS chronic rhinosinusitis
CRT chemoradiotherapy
CSOM chronic suppurative otitis media
CT computed tomography
cVEMP cervical vestibular-evoked myogenic potential
CWD canal-wall-down
CWU canal-wall-up
CXR chest X-ray
DVLA Driver and Vehicle Licensing Agency
DVT deep vein thrombosis
dW diffusion-weighted
EAC external auditory canal
EBER Epstein–Barr small non-coding RNAs
EBV Epstein–Barr virus
ECS extracapsular spread

xxi
 xxii Abbreviations

eGFR estimated glomerular filtration rate

EMG electromyography
ENG electronystagmography
ENoG electroneuronography
ENT ears, nose and throat
EPOS European Position Paper on Rhinosinusitis and Nasal Polyps
ESR erythrocyte sedimentation rate
ET endotracheal
ETT endotracheal tube
EUA examination under anaesthesia
FBC full blood count
FDG-PET fluorodeoxyglucose-positron emission tomography
FEES fibreoptic endoscopic evaluation of swallowing
FESS functional endoscopic sinus surgery
FLAIR fluid attenuation inversion recovery
FNA fine-needle aspiration
FNA-c fine-needle aspiration cytology
FRCS (ORL-HNS) Fellowship of the Royal College of Surgeons Otolaryngology – Head and
Neck Surgery
FRCS Fellowship of the Royal Colleges of Surgeons
GABHS Group A beta-haemolytic Streptococcus
GCS Glasgow Coma Scale
GORD gastro-oesophageal reflux disease
GOSH Great Ormond Street Hospital
GP general practitioner
GPA granulomatous polyangiitis
HB House–Brackmann
HDU high–dependency unit
HIV human immunodeficiency virus
HNSCC head and neck squamous cell carcinoma
HSV-1 herpes simplex virus-1
HZV herpes zoster vaccine
IAC internal auditory canal
ICA internal carotid artery
ICON-S I nternational Collaboration on Oropharyngeal Cancer Network for Staging
ICP intracranial pressure
IgE immunoglobulin E
IJV internal jugular vein
IMI Institute of Medical Illustrators
IMRT intensity-modulated radiotherapy
IMAX internal maxillary artery
IOOG International Otology Outcome Group
IT intratympanic
ITU intensive treatment unit
JCIE Joint Committee on Intercollegiate Examinations
KTP potassium-titanyl-phosphate
LA local anaesthetic
LLC lower lateral cartilage
LMA laryngeal mask airway
 Abbreviations xxiii

MACH-NC meta-analysis of chemotherapy in head and neck cancer

MACIS metastases, age, complete surgery, invasion, size
MCT medium-chain triglyceride
MDADI MD Anderson Dysphagia Inventory
MdDS mal de debarquement syndrome
MDT multidisciplinary team
MEI middle ear implant
MIBG meta-iodobenzylguanidine
MR magnetic resonance
MRA magnetic resonance angiography
MRCS Membership of the Royal Colleges of Surgeons
MRND modified radical neck dissection
MS multiple sclerosis
MUA manipulation under anaesthesia
NG nasogastric
NHS National Health Service
NHSP Newborn Hearing Screening Programme
NICU newborn intensive care unit
NIHL noise-induced hearing loss
non-EPI dwMRI non-echo planar diffusion-weighted magnetic resonance imaging
NPC nasopharyngeal carcinoma
NSAID nonsteroidal anti-inflammatory drugs
OAE otoacoustic emissions
OME otitis media with effusion
ORN osteoradionecrosis
OSA obstructive sleep apnoea
PATHOS post-operative adjuvant treatment for HPV-positive tumours
PC-BPPV posterior canal BPPV
PCD primary ciliary dyskinesia
PDA patent ductus arteriosus
PEG percutaneous endoscopic gastrostomy
PET-CT positron emission tomography–computed tomography
PICA posterior inferior cerebellar artery
PORP partial ossicular replacement prosthesis
PORT post-operative radiotherapy
PPIs proton pump inhibitors
PPPD persistent postural-perceptual dizziness
PTH parathyroid hormone
RA rheumatoid arthritis
RAI radioactive iodine
RCT randomised-controlled trial
RND radical neck dissection
RRP recurrent respiratory papillomatosis
RSTLs relaxed skin tension lines
RT radiotherapy
SCBU special care baby unit
SCC squamous cell carcinoma
SCIT subcutaneous immunotherapy
SCM sternocleidomastoid muscle
 xxiv Abbreviations

SH social history
SLE systemic lupus erythematosus
SLIT sublingual immunotherapy
SLT speech and language therapy
SMAS superficial muscular aponeurotic system
SMG submandibular gland
SND selective neck dissection
SNHL sensorineural hearing loss
SNUC sinonasal undifferentiated carcinoma
SOAL swallowing outcomes after laryngectomy
SPA sphenopalatine artery
SPECT single-photon emission computed tomography
SSNHL sudden sensorineural hearing loss
SSQ Sydney Swallow Questionnaire
SUV standardised uptake value
TFTs thyroid function tests
TM tympanic membrane
TMJ temporomandibular joint
TNM tumour/node/metastasis
TORP total ossicular replacement prosthesis
UICC Union for International Cancer Control
ULC upper lateral cartilage
UPSIT University of Pennsylvania Smell Identification Test
URTI upper respiratory tract infection
USS ultrasound scan
VEGF vascular endothelial growth factor
vHIT video head impulse test
VNG videonystagmography
VOG video-oculography
VOR vestibulo-ocular reflex
VPI velopharyngeal insufficiency
VRA visual reinforcement audiometry
WCC white cell count
WHO World Health Organisation
INTRODUCTION

1
JOSEPH MANJALY AND PETER KULLAR

You may remember in the early years of your training looking up to senior registrars who had
become Fellows of the Royal College of Surgeons, feeling that you had a long way to go before
you had the knowledge and experience to join them. As you progress through training and
the end of ST6 draws near, it’s not unheard of to start developing imposter syndrome. Are you
truly ready for this hurdle? Or have you somehow slipped under the radar because everyone
has assumed that you were doing fine? Is everything about to suddenly hit the fan with an
ignominious revelation that you eternally follow patients up in clinic and can only just about
do a tracheostomy?
And yet the FRCS (ORL-HNS), just like other exams you have passed along the way, is a very
passable exam. You’ve reached this point because you are capable of meeting that standard. Once
you have done so the next step will be to think about a consultant post, usually within 18 months
though that may seem a far-away idea at this point.
What has probably changed since your last exam are your circumstances. As a registrar the need
to be on top form every day, particularly on operating days, limits the number of late nights you
can reasonably spend revising. Gone are the string of post-nights ‘zero days’ you could use as a
senior house officer. You may have family responsibilities to juggle by now. The tools to be able
to ‘work smart’ are more crucial than ever and our book is written in this spirit.
The syllabus for this exam seems endless: essentially try and know everything about ENT and
its related specialities. There are many excellent texts and resources available for the task but
arguably the most useful information is the pragmatic, working knowledge and gems of wisdom
handed down by the preceding generations. In this book we have tried to bring these together in
one place.
More than just a question and answer book, we hope this book will act as a coaching manual.
Every section is centred on a combination of ‘model answers’, pearls of wisdom, checklists
( ✓) and pointers for further reading ( ). Rather than being an exhaustive ENT text, we hope
this book will guide you to exam success in a thorough yet efficient manner alongside your
work commitments. We have been comprehensive with topic selection. The viva topics included
in this book touch on nearly every subject that has come up in the exam in the 5 years prior to
publication.
We have gratefully called on contributions from colleagues around the country. All were identified
as high achievers with a skill for teaching and mentoring. Thankfully for us, all have responded
with enthusiasm and willingness to be a part of this project. All viva advice contributors have
passed the exam within the last 3 years, including multiple gold medal winners. We are sure that
many will go on to be leaders of their fields in the future.
The authority of this book is secured by our senior editors. In Manohar Bance, Neil Donnelly,
Ben Hartley, Richard Hewitt, James O’Hara, Hesham Saleh and James Tysome, we have had the
 2 Introduction

privilege of receiving internationally respected wisdom from current national and world-leading
clinicians. We are very grateful for their time and critical input.
Preparing for the FRCS (ORL-HNS) examination will be a tough journey – both for you and those
around you. We hope this book will help you prepare whether you’re a UK or international trainee.
It will be a time when your patient care significantly matures. Enjoy seeing the rewards of that.
You may end up strangely wishing you had gone through the whole thing earlier!
PERSONAL REFLECTIONS ON THE FRCS
(ORL-HNS) PART 1 EXPERIENCE

2
ALISON CARTER

Currently the earliest point in training to be eligible to sit the exam is the beginning of ST7. If you
are in a training programme that allows you to pick your jobs for the next year, it is important to
select carefully. Now may not be the time to rank the busiest job in the deanery or the one with the
longest commute. I returned to a hospital at which I had worked previously, where my colleagues
were supportive and understood that my main focus over the coming months was the exam.
I have summarised my approach to the exam but this of course is very individual.
Many of my successful colleagues approached things slightly differently, so it is worth talking to
those around you and so you can synthesise a strategy that suits you best. I hope this guide will
give you an idea of what worked for me and what may work for you.

6 Months Pre-exam
Applications will be via the JCIE website (www.jcie.org.uk) and require you to fill in an electronic
form with your work history, dates of your MRCS and university medical degree, a summary of
your operative experience (a PDF of your elogbook is sufficient), your curriculum vitae, and three
structured references from supervisors whom you have worked with in the last 2 years. If you are
in a UK training programme this must include one from your training programme director stating
that you have a ST6 ARCP outcome 1. The referees are asked to assess your diagnostic skills, clinical
management, operative skills, professionalism and probity and communication and language skills.
Getting the forms signed always takes longer than one might anticipate so make sure that you are
organised in getting this done.
At the point of application, you have to pay for both parts of the FRCS (at the time of writing: Part
1 – £536, Part 2 – £1,313, total £1,849). Most will elect to do Part 2 FRCS in the next available
sitting on the application form (3–4 months post Part 1). There have been occasions where the
second part has been oversubscribed and entry is granted in order of receipt of applications,
therefore in order to avoid any unnecessary stress or disappointment later an early application
is advised.
Over your training you have likely been building your CV with publications, quality improvement
projections and further degrees, but now is time to put all that to one side. Accept that for the 3–4
months before the exam, you will not be doing any of those things, and try and use the 6-month
mark before the Part 1 to finish outstanding projects so that you can start revising with a clean
slate. I was surprised at how understanding my colleagues and bosses were about this when
politely declining to take on any extra projects, and was usually met with ‘of course, you have
the exam – best of luck’.
 4 Personal Reflections on the FRCS (ORL-HNS) Part 1 Experience

4 Months Pre-exam
Gone are the days of university when you could dedicate hours on end to revision. You will likely
be working in a busy job with long days, may have accumulated other things in your life such as
partners and children and sadly dealing with sleep deprivation is probably not as easy as it once
was all those years ago. Remind yourself that most people sitting the exam are also facing the same
challenges, and you just have to manage it as best you can.
Look at your work week and try and identify areas where you can get some productive revision
time in. You may have a morning or afternoon in your timetable that can be used for revision.
Be disciplined in making sure that you use it effectively. Work out when you are at your most
productive. For me, I know that I work better in the morning, and on looking at my timetable, three
mornings I had to be at work for 7.30 a.m., but the other two were 9 a.m. Although it required a lot
of dedication, and some that the alarm was switched off for, for those 2 days a week, I would wake
up at 5.30 a.m. and get 2–3 hours done before work. In return, I never revised in the evenings,
and made sure that I enjoyed times out with friends or relaxing at home ‘guilt free’. Although
this worked for me, I know that not everyone would work best in the mornings, so be honest with
yourself as to what your golden hours are, make it happen and make sure you enjoy the other
hours and give yourself a break. At the weekend I had one day where I was productive (sometimes
both), but again never worked in the evenings.
I started my revision using a textbook to give an overview of all the areas of ENT. I read through
topic by topic, highlighting things I thought were important. Everyone responds differently to
different styles of books, and I would recommend asking your colleagues what they found helpful
previously and going to look at a few of them in the library or sample them online, before buying
one which you think you will like. You do not need a book that goes into intricate detail, this is
more for an overview of different topics, some of which you may not have had as much exposure
to in your training, and to jog your memory on those you have. Although most of the FRCS courses
are aimed at Part 2, there are some available for Part 1 and can help refining exam technique and
identify gaps in your knowledge.
It can also be good to think of something else other than your exams, such as a holiday to look
forward to, or perhaps a challenge to focus on training for a half marathon, enabling you to break
up your revision.

2 Months Pre-exam
I started to look at some example questions in the various books available (although some of
my colleagues did start this earlier alongside their reading). Some of the books available had
explanations attached to the answers so I used those ones preferentially as it is a good way to
continue your revision and to learn from your answers. If there was an area where I had not got
it right, or I thought it was a good ‘fact’, I wrote it down in my notes.

1 Month Pre-exam
Try and take some time off work before the exam. For me, this was December, and being around
Christmas, there were natural days off work which were helpful, and I did not have to take that
many days off surrounding them to take 2 weeks off prior to the exam, with a few interspersed
on calls. I kept my format the same, waking up and getting straight to work, and then using my
evenings to relax and put my laptop and books away.
Another random document with
no related content on Scribd:
 Figure 51. William Sellers

This paper had as great influence in America as Whitworth’s paper

of 1841 had in England. A committee was appointed to investigate
the question and recommend a standard. On this committee, among
others, were William B. Bement, C. T. Parry of the Baldwin
Locomotive Works, S. V. Merrick, J. H. Towne, and Coleman Sellers.
Early in the next year the committee reported in favor of the Sellers
standard, the Franklin Institute communicated their findings to other
societies, and recommended the general adoption of the system
throughout the country. The Sellers’ thread was adopted by the
United States Government for all government work in 1868, by the
Pennsylvania Railroad in 1869, the Master Car Builders’ Association
in 1872, and soon became practically universal. After exhaustive
investigation the Sellers’ form of thread was adopted in 1898 by the
International Congress for the standardization of screw threads, at
Zurich, and is now in general use on the continent of Europe.[209]
[209] For the discussion of the Sellers’ screw thread and the
circumstances surrounding its adoption, see: Journal of the Franklin
Institute, Vol. LXXVII, p. 344; Vol. LXXIX, pp. 53, 111; Vol. CXXIII, p. 261;
Vol. CXXV, p. 185.

In 1868 William Sellers organized the Edgemoor Iron Company

which furnished the iron work for the principal Centennial buildings
and all the structural work of the Brooklyn Bridge. In the
development of this business, he led the way in the distinctly
American methods and machinery by which the building of bridges
has been, to a great extent, put upon a manufacturing basis. This
involved the design and introduction of hydraulic machinery, large
multiple punches, riveters, cranes, boring machines, etc.
The excellence of his machinery soon brought him into contact
with government engineers and throughout his life his influence in
the War and Navy Departments was great. In 1890 the Navy
Department called for bids on an eight-foot lathe, with a total length
of over 128 feet, to bore and turn sixteen-inch cannon for the Naval
Gun Factory at Washington. Sellers disapproved of the design and
refused to bid on it. He proposed an alternative one of his own,
argued its merits in person before the Board of Engineers, and
secured its adoption and a contract for it. This great lathe, weighing
over 500,000 pounds, has attracted the attention of engineers from
all parts of the world. In 1873 Mr. Sellers reorganized the William
Butcher Steel Works as the Midvale Steel Company and became its
president. Under his management the company grew rapidly, and
later became a leader in production of heavy ordnance.
It was here that Frederick W. Taylor began in 1880 his work on the
art of cutting metals, which resulted in modern high-speed tool steels
and a general re-design of machine tools. These experiments,
covering a period of twenty-six years, cost upwards of $200,000. Mr.
Taylor has frequently acknowledged his indebtedness in this work to
the patience and courage of Mr. Sellers, who was then an old man
and might have been expected to oppose radical change. It was he
who made the work possible, however, and he supported Taylor
unwaveringly in the face of constant protests.[210] Mr. Sellers was a
man of commanding presence, direct but gracious in manner, who
won and held the respect and loyalty of all about him. His judgment
was almost unerring and he dominated each of the great
establishments he built up.
[210] F. W. Taylor: Paper on the “Art of Cutting Metals,” Trans. A. S. M. E.,
Vol. XXVIII, p. 34.

The firm of William Sellers & Company had another master mind
in that of Dr. Coleman Sellers, a second cousin of William
Sellers.[211] He was born in Philadelphia in 1827, his father, Coleman
Sellers, being also an inventor and mechanic. Like Nasmyth he
spent his school holidays in his father’s shop, which was at
Cardington. In 1846, when he was nineteen years old, he went to
Cincinnati and worked in the Globe Rolling Mill, operated by his elder
brothers, where the first locomotives for the Panama Railroad were
built; and in two years he became superintendent. In 1851 he
became foreman of the works of James and Jonathan Niles, who
were then in Cincinnati and building locomotives. Six years later he
returned to Philadelphia, became chief engineer of William Sellers &
Company, and remained with them for over thirty years, becoming a
partner in 1873. During these years he designed a wide range of
machinery, which naturally covered much the same field as that of
William Sellers, but his familiarity with locomotive work especially
fitted him for the design of railway tools. His designs were original,
correct and refined. The Sellers coupling was his invention and he
did much to introduce the modern systems of power transmission.
[211] See Trans. A. S. M. E., Vol. XXIX, p. 1163; Cassier’s Magazine,
August, 1903, p. 352; Journal of the Franklin Institute, Vol. CXLIX, p. 5.

Doctor Sellers was a good physicist, an expert photographer,

telegrapher, microscopist, and a professor in the Franklin Institute,
his lectures always drawing large audiences. Like William Sellers, he
was a member of most of the great engineering and scientific
societies, here and abroad; and he was president of the American
Society of Mechanical Engineers, of which he was a charter
member. He was received with the greatest distinction in his visits to
Europe. In 1886 impaired health compelled his relinquishing regular
work and he resigned his position of engineer for William Sellers &
Company, being succeeded by his son, the present president of the
company. His last great work was in connection with the power
development of Niagara Falls. He was engineer for the Cataract
Construction Company and served on the commission which
determined the types of turbines and generators and the methods of
power transmission finally adopted. Among the others on this
commission were Lord Kelvin, Colonel Turretini, the great Swiss
engineer, and Professor Unwin, and its report forms the foundation
of modern large hydro-electric work. William Sellers & Company has
a unique distinction among the builders of machine tools in having
had the leadership of two such men as William and Coleman Sellers.
William B. Bement, the son of a Connecticut farmer and
blacksmith, was born at Bradford, N. H., in 1817. His education was
obtained in the district schools and in his father’s blacksmith shop.
His mechanical aptitude was so clear that he was apprenticed to
Moore & Colby, manufacturers of woolen and cotton machinery at
Peterboro, N. H. His progress at first was rapid. Within two years he
became foreman, and on the withdrawal of one of the partners, was
admitted into the firm. He continued there three years, already giving
much thought to machine tools, for which he saw the rising need. In
1840 he went to Manchester and entered the Amoskeag shop when
it was just finished, remaining there two years as a foreman and
contractor under William A. Burke, to whom we have referred
elsewhere. From there Bement went to take charge of a shop for
manufacturing woolen machinery at Mishawaka, Ind. Unfortunately it
was burned to the ground while Bement had gone back to New
Hampshire for his family, so that when he returned with them he
found himself without employment and with only ten dollars in hand.
For the time being he worked as a blacksmith and gunsmith, and
made an engine lathe for himself in the shop of the St. Joseph Iron
Company, which gave him permission to use their tools in return for
the use of his patterns to make a similar machine for themselves.
Much of the work in making this lathe was done by hand as there
was no planer within many hundred miles. The St. Joseph Iron
Company, seeing his work, offered him the charge of their shop, to
which he agreed, provided the plant were enlarged and equipped
with proper tools. This was done, but just as everything was
completed this plant also was burned down. Bement had plans for
another shop ready the following day, went into the woods with
others, cut the necessary timber, and a new shop was soon
completed. He remained there for three years, constructing a variety
of machine tools, one of which was a gear cutter said to have been
the first one built in the West, or used beyond Cleveland.
Figure 52. Coleman Sellers
 Figure 53. William B. Bement

He returned to New England as a contractor in the Lowell Machine

Shop under Burke, who had gone there from the Amoskeag Mills in
1845. On account of Bement’s resourcefulness and skill in
designing, Burke induced him to relinquish his contracts and take
charge of their designing, which he did for three years, his residence
at Lowell covering in all about six years.
In 1851 Elijah D. Marshall, who had established a business of
engraving rolls for printing calicos in 1848 and had a small shop at
Twentieth and Callowhill Streets in Philadelphia, offered Bement a
partnership. He moved to Philadelphia in September of that year,
and with Marshall and Gilbert A. Colby, a nephew, he began the
manufacture of machine tools under the name of Marshall, Bement &
Colby, thus starting only a year or so after Sellers. Marshall was a
large man, dignified and deliberate in speech. Bement was strong,
vigorous, a born designer, a remarkably rapid draftsman, and had a
capacity for work rarely equalled. Colby was also a man of
considerable mechanical ability, with advanced business ideas. Their
shop consisted of a single three-storied, stone, whitewashed
building, 40 by 90 feet. Their entire machine shop was on the first
floor, with a 10- by 12-foot room for an office. The engine, boiler and
blacksmith shop were in small outbuildings. Part of the second floor
was rented to another factory and the rest was sometimes used for
religious meetings, while the third floor was used for engraving
printing rolls. Their tools were few and crude; among them were a
36-inch lathe with a wooden bed and iron straps for ways, and a 48-
inch by 14-foot planer with ornate Doric uprights. Marshall and Colby
soon retired, the latter going to Niles, Mich., where he was very
successful. James Dougherty, an expert foundryman, and George C.
Thomas entered the firm, which became Bement & Dougherty, the
plant being known as the “Industrial Works.” Mr. Thomas contributed
considerable capital, and a new shop and a foundry were built. At
the same time they installed a planer 10 feet wide by 8 feet high, to
plane work 45 feet long, a notable tool for that day.
After a few years of struggle, the plant began to grow rapidly and
at one time was the largest of its kind in the country. Bement and
Sellers were among the first to concentrate wholly on tool building.
They confined themselves to work of the highest quality. Both made
much heavier tools, as we have said, than the New England
builders, their only competitors, and in a short time had established
great reputations. Bement relied little on patent protection, trusting to
quality and constant improvement. Thomas retired from the
partnership in 1856 and Dougherty in 1870; and Clarence S. Bement
joined the firm, which became William B. Bement & Son. John M.
Shrigley became a partner in 1875, William P. Bement in 1879, and
Frank Bement in 1888.
Frederick B. Miles was an employee of Bement & Dougherty who
established a tool business under the name of Ferris & Miles, which
afterward became the Machine Tool Works. While head of these
works, Miles greatly improved the steam hammer, particularly its
valve mechanism, and many details of what is known as the Bement
hammer were invented by Miles. In 1885 the Machine Tool Works
consolidated with William Bement & Son, forming Bement, Miles &
Company. Mr. Miles was an accomplished engineer and designer,
with the unusual equipment of six languages at his command, an
asset of value in the firm’s foreign business. William Bement, Senior,
died in 1897, and in 1900 the business became a part of the Niles-
Bement-Pond Company. Mr. Miles retired at that time and has not
since been active in the tool business.[212]
[212] Most of the foregoing details in regard to the Bement & Miles Works
have been obtained from Mr. Clarence S. Bement and Mr. W. T. Hagman,
their present general manager.

Although Bement and Sellers contributed more to the art of tool

building than any of the other Philadelphia mechanics, some of these
others ought to be mentioned. Matthias W. Baldwin, a native of New
Jersey, began as a jeweler’s apprentice. In partnership with David H.
Mason he began making bookbinders’ tools, to which he added in
1822 the engraving of rolls for printing cotton goods and later of bank
notes. From the invention and manufacture of a variety of tools used
in that business they were led gradually into the machine tool
business, the building of hydraulic presses, calender rolls, steam
engines, and finally locomotives. In 1830 Baldwin built a model
locomotive for the Peale Museum which led to an order from the
Philadelphia & Germantown Railroad for an engine which was
completed in 1832 and placed on the road in January, 1833. An
advertisement of that time says: “The locomotive engine built by Mr.
M. W. Baldwin of this city will depart daily, when the weather is fair,
with a train of passenger cars. On rainy days horses will be attached
in the place of the locomotive.”
From this beginning has sprung the Baldwin Locomotive Works,
which employs approximately 20,000 men. In 1834 they built five
locomotives; in 1835, fourteen; in 1836, forty. Their one thousandth
locomotive was built in 1861; the five thousandth in 1880 and the
forty thousandth in 1913. These works have naturally greatly
influenced the neighboring tool makers. From the beginning, both
Bement and Sellers specialized on railway machinery and they have
always built a class of tools larger than those manufactured in New
England.
The Southwark Foundry was established in 1836, first as a
foundry only, but a large machine shop was soon added. The owners
were S. V. Merrick, who became the first president of the
Pennsylvania Railroad Company, and John Henry Towne, who was
the engineering partner. The firm designed and built steam engines
and other heavy machinery and introduced the steam hammer into
the United States under arrangement with James Nasmyth. From the
designs of Capt. John Ericsson they built the engines for the
“Princeton,” the first American man-of-war propelled by a screw, and
later were identified with the Porter-Allen steam engine. Mr. Towne
withdrew from the firm about 1848, and the firm name became
successively Merrick & Son, Merrick & Sons, Henry G. Morris, and
finally the Southwark Foundry & Machine Company.
I. P. Morris & Company came from Levi Morris & Company,
founded in 1828, and for many years were engaged in a similar
work. In 1862 Mr. J. H. Towne, above referred to, was admitted to
the firm as the engineering partner, and the firm name then became
I. P. Morris, Towne & Company, until about 1869 when Mr. Towne
withdrew. At his withdrawal the firm name was restored to its original
form, I. P. Morris & Company. It is now a department of the Cramp
Ship Building Company. During the Civil War the works were
occupied largely in building engines and boilers for government
vessels, and blast furnace and sugar mill machinery. During this
period Henry R. Towne, son of J. H. Towne, entered the works as an
apprentice, served in the drawing room and shops, and finally was
placed in charge of the erection at the navy yards of Boston and
Kittery of the engines, boilers, etc., built for two of the double-
turreted monitors. Returning to Philadelphia, he was made assistant
superintendent of the works.
J. H. Towne was a mechanical engineer of eminence in his day,
whose work as a designer showed unusual thoroughness and finish.
He was a warm friend and admirer of both William and Coleman
Sellers, and through his influence, Henry R. Towne was at one time
a student apprentice in the shops of William Sellers & Company,
acquiring there an experience which had a marked influence on his
future work. Both of the firms with which J. H. Towne was connected
built machine tools for themselves and for others, especially of the
heavier and larger kinds, and thus were among the early tool
builders. I. P. Morris & Company, about 1860, designed and built for
their own use what was then the largest vertical boring mill in this
country.[213]
[213] From correspondence with Mr. Henry R. Towne.

It may surprise some to learn that the well-known New England

firm, the Yale & Towne Manufacturing Company in Stamford, Conn.,
is a descendant of these Philadelphia companies. It was organized
in October, 1868, by Linus Yale, Jr., and Henry R. Towne, who were
brought together by William Sellers. Mr. Yale died in the following
December. This company, under the direction and control of Mr.
Towne, has had a wide influence on the lock and hardware industry
in this country. While the products of the Yale & Towne
Manufacturing Company have always consisted chiefly of locks and
related articles, they have added since 1876 the manufacture of
chain blocks, electric hoists, and, during a considerable period, two
lines allied to tool building, namely, cranes and testing machines.
This company was the pioneer crane builder of this country,
organizing a department for this purpose as early as 1878, and
developing a large business in this field, which was sold in 1894 to
the Brown Hoisting Machine Company of Cleveland, Ohio. The
building of testing machines was undertaken in 1882, to utilize the
inventions of Mr. A. H. Emery, and was continued until 1887, when
this business was sold to William Sellers & Company, for the same
reason that the crane business was sold; namely, that both were
incongruous with the other and principal products of the company.
In recent years the Bilgram Machine Works, under the leadership
of Hugo Bilgram, an expert Philadelphia mechanic, has made
valuable contributions to the art of accurate gear cutting.
In the cities between New York and Philadelphia, and here and
there in the smaller towns of Pennsylvania, are several tool builders
of influence. Gould & Eberhardt in Newark is one of the oldest firms
in the business, having been established in 1833. Ezra Gould, its
founder, learned his trade at Paterson, and started in for himself at
Newark in a single room, 16 feet square. Within a few years the
Gould Machine Company was organized, the business moved to its
present location, and a line of lathes, planers and drill presses was
manufactured. To these they added fire engines. Ulrich Eberhardt
started as an apprentice in 1858 and became a partner in 1877, the
firm name becoming E. Gould & Eberhardt, and later Gould &
Eberhardt. Mr. Gould retired in 1891, and died in 1901. Mr. Eberhardt
also died in 1901; the business has since been incorporated and is
now under the management of his three sons. They employ about
400 men in the manufacture of gear and rack cutting machinery and
shapers.
The Pond Machine Tool Company, which moved from Worcester
to Plainfield, N. J., in 1888, was founded by Lucius W. Pond.[214] It is
a large and influential shop and one of the four plants of the Niles-
Bement-Pond Company. Their output is chiefly planers, boring mills
and large lathes.
[214] See p. 222.

The Landis Tool Company, of Waynesboro, Pa., builders of

grinding machinery, springs from the firm of Landis Brothers,
established in 1890 by F. F. and A. B. Landis. One was
superintendent and the other a tool maker in a small plant building
portable engines and agricultural machinery. A small Brown &
Sharpe grinding machine was purchased for use in these works. Mr.
A. B. Landis became interested in the design of a machine more
suited to their particular work, and from this has developed the
Landis grinder.
 CHAPTER XX
THE WESTERN TOOL BUILDERS
Prior to 1880 practically all of the tool building in the United States
was done east of the Alleghenies. The few tools built here and there
in Ohio and Indiana were mostly copies of eastern ones and their
quality was not high. In fact, there were few shops in the West
equipped to do accurate work. “Chordal’s Letters,” published first in
the American Machinist and later in book form,[215] give an excellent
picture of the western machine shop in the transition stage from
pioneer conditions to those of the present day.
[215] Henry W. See: “Extracts from Chordal’s Letters”; McGraw-Hill Book
Co., N. Y. 12th Edition. 1909.

Good tool building appeared in Ohio in the early eighties, and

within ten years its competition was felt by the eastern tool builders.
The first western centers were Cleveland, Cincinnati and Hamilton.
Of these, Cleveland seems to have been the first to build tools of the
highest grade.
We have already noted that the Pratt & Whitney shop in Hartford
furnished Cleveland with a number of its foremost tool builders. The
oldest of these and perhaps the best known is the Warner & Swasey
Company. This company has the distinction, shared with only one
other, of having furnished two presidents of the American Society of
Mechanical Engineers. Oddly enough the other company is also a
Cleveland firm, the Wellman, Seaver, Morgan Company, builders of
coal- and ore-handling machinery, and of steel mill equipment.
Worcester E. Warner, of the Warner & Swasey Company, was
born at Cummington, Mass., in 1846. Although a farmer’s son and
denied a college education, he had access in his own home to an
admirable library, which he used to great advantage. When nineteen
years old he went to Boston and learned mechanical drawing in the
office of George B. Brayton. Shortly afterwards he was transferred to
the shop at Exeter, N. H., where he first met Ambrose Swasey. Mr.
Swasey was born at Exeter, also in 1846, went to the traditional “little
red schoolhouse,” and learned his trade as a machinist in the shop
to which Warner came. In 1870 they went together to Hartford,
entered the Pratt & Whitney shop as journeymen mechanics, and in
a short time had become foremen and contractors. Mr. Swasey soon
gained a reputation for accurate workmanship and rare ability in the
solution of complex mechanical problems. He had charge of the gear
department, and invented and developed a new process of
generating spur gear teeth, which was given in a paper before the
American Society of Mechanical Engineers.[216] Mr. Warner, also,
became one of the company’s most trusted mechanics, was head of
the planing department, and had charge of the Pratt & Whitney
exhibit at the Centennial Exposition in Philadelphia.
[216] Trans. A. S. M. E., Vol. XII, p. 265.

In 1881 they left Hartford and went first to Chicago, intending to

build engine lathes, each putting $5000 into the venture; but finding
difficulty in obtaining good workmen there, they moved in about a
year to Cleveland, where they have remained. Their first order was
for twelve turret lathes, and they have built this type of machine ever
since. At various times they have built speed lathes, die-sinking
machines, horizontal boring mills, and hand gear-cutters, but they
now confine their tool building to hand-operated turret lathes. They
have never built automatics.
Figure 54. Worcester R. Warner
Figure 55. Ambrose Swasey
 The building of astronomical instruments was not in their original
scheme, but Mr. Warner’s taste for astronomy and Mr. Swasey’s skill
in intricate and delicate mechanical problems, led them to take up
this work. These instruments, usually designed by astronomers and
instrument makers, were in general much too light; at least the large
ones were. From their long experience as tool builders, Warner and
Swasey realized that strength and rigidity are quite as essential as
accuracy of workmanship where great precision is required. The
design of a large telescope carrying a lens weighing over 500
pounds at the end of a steel tube forty or sixty feet long, and
weighing five or six tons, which must be practically free from flexure
and vibration and under intricate and accurate control, becomes
distinctly an engineering problem. To this problem both Mr. Warner
and Mr. Swasey brought engineering skill and experience of the
highest order.
When the trustees of the Lick Observatory called in 1886 for
designs for the great 36-inch telescope, Warner & Swasey submitted
one which provided for much heavier mountings than had ever been
used before, and heavier construction throughout. They were
awarded the contract and the instrument was built and installed
under Mr. Swasey’s personal supervision. It is located on the very
top of Mount Hamilton in California, 4200 feet above sea-level; and
to give room for the observatory 42,000 tons of rock had to be
removed. The great instrument, weighing with its mountings more
than forty tons, “was transported in sections, over a newly made
mountain road, sometimes in a driving snowstorm, with the wind
blowing from sixty to eighty miles an hour.”[217]
[217] Cassier’s Magazine, March, 1897, p. 403.

As is well known, the instrument was a brilliant success. The

Warner & Swasey Company has since designed and built the
mountings for the United States Naval Observatory telescope, the
40-inch Yerkes telescope, the 72-inch reflecting telescope for the
Canadian Government, and the 60-inch reflecting telescope for the
National Observatory at Cordoba, Argentina, the largest in use in the
southern hemisphere. In addition to this large work, the firm has built
meridian circles, transits and other instruments for astronomical
work, range finders for the United States Government, and
introduced the prismatic binocular into this country.
In connection with this astronomical work Mr. Swasey designed
and built a dividing engine capable of dividing circles of 40 inches in
diameter with an error of less than one second of arc. A second of
arc subtends about one-third of an inch at the distance of one mile.
Although the graduations on the inlaid silver band of this machine
are so fine that they can scarcely be seen with the naked eye, the
width of each line is twelve times the maximum error in the automatic
graduations which the machine produces.
Although their reputation as telescope builders is international,
Warner & Swasey are, and always have been, primarily tool builders.
They were not the first to build tools in the Middle West, but they
were the first to turn out work comparable in quality with that of the
best shops in the East.
The Warner & Swasey shop has had the advantage of other good
mechanics besides its proprietors. Walter Allen, an expert tool
designer, did his entire work with them, rising from apprentice to
works manager. Frank Kempsmith, originally a Brown & Sharpe
man, was at one time their superintendent. Lucas, of the Lucas
Machine Tool Company, was a foreman. George Bardons, who
served his apprenticeship with Pratt & Whitney, went west with
Warner and Swasey when they started in business and was their
superintendent; and John Oliver, a graduate of Worcester
Polytechnic, was their chief draftsman. The last two left Warner &
Swasey in 1891 and established the firm of Bardons & Oliver for
building lathes.
Another old Pratt & Whitney workman is A. W. Foote of the Foote-
Burt Company, builders of drilling machines. Unlike the others,
however, Foote did not work for Warner & Swasey.
The first multi-spindle automatic screw machines were
manufactured in Cleveland. The Cleveland automatic was developed
in the plant of the White Sewing Machine Company for their own
work, and its success led to the establishment of a separate
company for its manufacture. The Acme automatic was invented by
Reinholdt Hakewessel and E. C. Henn in Hartford. Mr. Hakewessel
was a Pratt & Whitney man and Mr. Henn a New Britain boy, who
had worked first in Lorain and Cincinnati and then for twelve years in
Hartford with Pratt & Cady, the valve manufactures. In 1895 Henn
and Hakewessel began manufacturing bicycle parts in a little
Hartford attic, developing for this work a five-spindle automatic.
Seven years later the business was moved to Cleveland, where it
became the National-Acme Manufacturing Company, organized by
E. C. and A. W. Henn and W. D. B. Alexander, who came from the
Union Steel Screw Works. Their business of manufacturing
automatic screw machinery and screw machine products has grown
rapidly and is now one of the largest industries in Cleveland.
The White Sewing Machine Company and the Union Steel Screw
Works were among the first in Cleveland to use accurate methods
and to produce interchangeable work. It was at the Union Steel
Screw Works that James Hartness, of the Jones & Lamson Machine
Company, got his first training in accurate work. Their shop practice
was good and was due to Jason A. Bidwell, who came from the
American Tool Company of Providence.
The Standard Tool Company is an offspring of Bingham &
Company, Cleveland, and of the Morse Twist Drill Company of New
Bedford, Mass. From the Standard Tool Company has come the
Whitman-Barnes Company of Akron, and from that the Michigan
Twist Drill and Machine Company.
Newton & Cox was established in 1876, and built planers and
milling machines. Mr. Newton sold his share in the business to F. F.
Prentiss in 1880, went to Philadelphia, and started the Newton
Machine Tool Works. Cox & Prentiss later became the Cleveland
Twist Drill Company. They drifted into the drill business through not
being able to buy such drills as they required. They began making
drills first for themselves, then for their friends, and gradually took up
their manufacture, giving up the business in machine tools.
Cincinnati is said to have upwards of 15,000 men engaged in the
tool building industry, and to be the largest tool building center in the
world. There are approximately forty firms there engaged in this
work, many of them large and widely known.
This development, which has taken place within the past thirty-five
years, may possibly have sprung indirectly from the old river traffic.
Seventy years ago this traffic was large, and Cincinnati did the
greater part of the engine and boat building and repair work. When
the river trade vanished, the mechanics engaged in this work were
compelled to turn their attention to something else, and there may be
some significance in the coincidence of the rise of tool building with
the decline of the older industry.
There had been more or less manufacturing in Cincinnati for many
years, but little of it could be described as tool building. Miles
Greenwood established the Eagle Iron Works in 1832 on the site
now occupied by the Ohio Mechanics Institute. It comprised a
general machine shop, an iron foundry, brass foundries, and a
hardware factory which rivaled those of New England, employing in
all over 500 men. The hardware factory was important enough to
attract the special attention of the English commissioners who visited
this country in 1853.
In the fifties and early sixties, Niles & Company built steamboat
and stationary engines, locomotives and sugar machinery, and
employed from 200 to 300 men. This company was the forerunner of
the present Niles Tool Works in Hamilton. Lane & Bodley were
building woodworking machinery about the same time, and J. A. Fay
& Company, another firm building woodworking machinery, which
started in Keene, N. H., began work in Cincinnati in the early sixties.
The first builder of metal-working tools in Cincinnati was John
Steptoe; in fact, he is said to have been for many years the only tool
builder west of the Alleghenies. Steptoe came to this country from
Oldham, England, some time in the forties. It is said that he was a
foundling and that his name came from his having been left on a
doorstep. He was married before he came to Cincinnati, and had
served an apprenticeship of seven years, although he was so young
in appearance that no one would believe it. After working some time
for Greenwood, he started in business for himself, making a foot
power mortising machine and later a line of woodworking tools. The
first metal-working tool which he built was a copy of the Putnam
lathe. With Thomas McFarlan, another Englishman, he formed the
firm of Steptoe & McFarlan, and his shop, called the Western
Machine Works, employed by 1870 about 300 men. Their old
payrolls contain the names of William E. Gang of the William E.